Population Health Management Through Care Coordination and Intervention

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Population health management is the process of implementing strategies to address population health needs and control problems at the population level.

Jointly owned by the Johns Hopkins Health System and the Johns Hopkins University School of Medicine, Johns Hopkins HealthCare (JHHC) develops and manages medical care contracts with organizations, government programs, and health care providers for more than 350,000 plan members. JHHC uses a population health management approach to improve health care outcomes and control costs.

Using data from the ACG System, JHHC’s population health management approach has led to decreases in hospitalizations, emergency room visits, readmissions and total cost of care for an underserved population in Baltimore City (-$1,643 per beneficiary per quarter). Read the complete Case Study here.

What is the ACG System?

The ACG System explains and predicts how health care resources are delivered and consumed. It identifies persons who are likely to become high-resource users or to become hospitalized, provides important clinical context to aid in managing patient care, and makes available customized models unique to each organization.